Systems and methods for assessing and training wrist joint proprioceptive function

ABSTRACT

A comprehensive system for treatment of wrist joint proprioception. The system includes a manipulandum unit and a controller. The unit includes a base, a handle, a linkage assembly, and motors. The base supports a subject&#39;s forearm, and the handle is gripped by the palm. The linkage assembly connects the handle to the base, and establishes three DOFs. The motors are operatively connected to the linkage assembly. The controller is programmed to actuate, and receive feedback information from, each of the plurality of motors. Further, the controller is programmed to perform wrist proprioception assessment operations by actuating the plurality of motors to effectuate movement of the handle relative to the base in a prescribed manner indicative of position motion sense acuity as an objective measure of wrist proprioception functioning. The controller is optionally further programmed to perform rehabilitation training via controlled operation of the unit and a virtually reality environment.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a Continuation of Non-Provisional patent applicationSer. No. 15/073,262, filed Mar. 17, 2016, entitled “Systems and Methodsfor Assessing and Training Wrist Joint Proprioceptive Function,” whichclaims the benefit of the filing date of U.S. Provisional PatentApplication Ser. No. 62/136,065, filed Mar. 20, 2015, entitled “Systemsand Methods for Assessing and Training Wrist Joint ProprioceptiveFunction,” which are herein incorporated by reference.

BACKGROUND

The present disclosure relates to automated manipulation of a humansubject's wrist joint. More particularly, it relates to automatedsystems and methods for assessing the proprioceptive status or functionat the wrist joint, and optionally for improving proprioceptive functionthrough proprioceptive sensory training.

Broadly defined, proprioception refers to the sense of body awareness.This awareness is based on signals from the receptors embedded injoints, muscles, tendons and skin. Classically, four properties ofproprioceptive function are distinguished: passive motion sense, activemotion sense, limb position sense, and the sense of heaviness. Jointproprioceptive signals are essential for intact monosynaptic musclestretch reflexes and polysynaptic postural reflexes that are involved inbalance control during standing and locomotion. They are also vital forcontrolling fine-motor voluntary movements such as grasping, reaching orwriting with the hand.

It is well established that the processing of proprioceptive informationis important for the neural control of movement. Conversely, the loss ofproprioception negatively impacts the reflexive control of balance, andseverely impairs spatial as well as temporal aspects of voluntarymovements. Clinical studies have documented that proprioceptive lossdebilitates even seemingly simple actions like cutting, and that suchimpairments are not restored by using vision as a sensory substitute.Numerous neurological and orthopedic conditions are associated withproprioceptive and kinaesthetic impairment such as stroke, Parkinson'sdisease, focal dystonia, peripheral sensory neuropathies, or orthopedicinjuries to ligaments, joint capsules and muscles.

Despite the recognition that proprioceptive deficits are the mostfrequent long-term side effect after brain damage, there is noestablished, precise method available in clinical settings to assessproprioceptive function. Recognized clinical tests to assessproprioceptive acuity are coarse. For example, the Nottingham SensoryAssessment (NSA) test and the Rivermead Assessment of SomatosensoryPerformance (RASP) test are based on detecting a subject's capability todiscriminate the upwards and downwards position of a single limb segment(i.e., finger or toe). Although the loss of limb proprioception mayseverely impact the effectiveness of available rehabilitation protocolsaiming to restore motor function, the presence of an objective, accurateand reliable method to assess proprioceptive function is still missingin rehabilitation practice.

An alternative approach to assess proprioceptive function is to obtainpsychophysical thresholds for joint position sense (JPS), motion sense(kinesthesia), and sense of tension or force. These threshold huntingmethods yield two types of thresholds: a detection threshold, which isthe smallest perceivable stimulus change (e.g., a position, motion orforce), and a discrimination threshold, which is the just noticeabledifference (JND) between two perceived stimuli. The detection thresholdis considered a measure of the sensitivity, while the discriminationthreshold represents a measure of acuity. In contrast to joint matchingmethods that rely on active motion of the test person, threshold huntingparadigms often use specialized equipment that passively moves aperson's limb in a highly controlled manner. Objective measurements ofJPS have been obtained through the use of various instruments such asgoniometers or inclinometers. Joint matching paradigms that mimicclinical testing have been most common to determine a JND threshold forJPS, but not for joint motion sense. However, recent research indicatedthat psychophysical threshold methods yield a more precise estimate of alimb position discrimination threshold than joint position matchingmethods, and passive motion testing results in lower thresholds thantests involving active motion.

More recently, it has been suggested that haptic technology or roboticdevices may be useful for obtaining sense thresholds of the hand orfingers. However, most robotic devices have focused on testing singleDegree of Freedom (DOF) joints such as the elbow or were only capable ofdisplacing or moving a joint in a single plane (e.g.,dorsiflexion/plantarflexion of the ankle). This approach overtlyrestricts the types of joints that can be investigated, or it providesonly partial information on the proprioceptive status of a joint.Moreover, while robotic-based rehabilitation systems have been suggestedthat may entail active limb movement with more than a single DOF, suchsystems do not consider, let alone address, the possibility of automatedassessment of proprioceptive function of a multi-plane of movementjoint, such as the wrist joint.

In light of the above, a need exists for proprioceptive functionassessment systems for joints having more than one plane of movement, aswell as for systems having an integrated capability of assessment ofproprioceptive function and proprioceptive training.

SUMMARY

Some aspects of the present disclosure are directed toward a wrist jointproprioception system. The system includes a manipulandum unit and acontroller. The manipulandum unit includes a base, a handle, a linkageassembly, and a plurality of motors. The base is configured to support asubject's forearm. The handle is configured to be gripped by a subject'shand. The linkage assembly connects the handle to the base, andestablishes three degrees of freedom of movement of the handle relativeto the base. Each of the plurality of motors is operatively connected tothe linkage assembly. The controller is electronically connected to themanipulandum unit and is programmed to actuate, and receive feedbackinformation from, each of the plurality of motors. Further, thecontroller is programmed to perform a proprioception assessmentoperation for objectively measuring proprioceptive function of asubject's wrist joint by actuating at least one of the plurality ofmotors to effectuate movement of the handle relative to the base in apre-determined manner. The assessment operation includes a positionsense routine in which the plurality of motors is actuated by thecontroller to establish a reference position of the handle relative tothe base. The position sense routine further includes one or more of themotors moving the handle about a first axis from the reference positionto a standard position, and from the standard position back to thereference position. The position sense routine further includes one ormore of the motors moving the handle about the first axis from thereference position to a first comparison position, and from the firstcomparison position to the reference position. In this regard, thecontroller is programmed to establish a pre-determined differencebetween the standard position and the first comparison position. Asubject's ability to perceive the difference is indicative of asubject's proprioceptive wrist position sense acuity as an objectivemeasure of a subject's wrist joint proprioceptive function.

In some embodiments, the proprioceptive function implicated by theposition sense routine relates to the subject's perception of anabsolute change in an articulated position of the wrist joint, and inother embodiments relates to discrimination between differentarticulated positions of the wrist joint. In yet other embodiments, thecontroller is programmed to perform one or more motion sense routinesthat implicate a subject's ability to perceive motion of the wrist jointand/or discrimination between different velocities of movement. In yetother embodiments, the controller is programmed to perform arehabilitation training operation via controlled operation of themanipulandum unit and a virtually reality environment. In yet otherembodiments, the manipulandum unit includes a first motor connected tothe linkage assembly so as to control articulation of the handle aboutan FE axis of the unit (inducing flexion-extension of the subject'swrist joint), second and third motors connected to the linkage assemblyso as to control articulation of the handle about an AA axis of the unit(inducing abduction-adduction of the subject's wrist joint), and afourth motor connected to the linkage assembly so as to controlarticulation of the handle about a PS axis of the unit (inducingpronation-supination of the subject's hand).

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a block diagram of a wrist joint proprioception system inaccordance with principles of the present disclosure;

FIGS. 2A and 2B are perspective views of a manipulandum unit useful withthe system of FIG. 1;

FIG. 3 is a partially exploded view of the manipulandum unit of FIG. 2A;

FIG. 4 is an exploded view of a PS transmission sub-assembly of themanipulandum unit of FIG. 2A;

FIG. 5 is an exploded view of an FE transmission sub-assembly of themanipulandum unit of FIG. 2A;

FIG. 6A is a side view of the manipulandum unit of FIG. 2A;

FIG. 6B is a top view of the manipulandum unit of FIG. 2A;

FIG. 6C is a rear view of the manipulandum unit of FIG. 2A;

FIG. 7 is a block diagram of a sensory assessment program useful withthe system of FIG. 1;

FIG. 8 is a simplified illustration of a subject interfacing with themanipulandum unit of FIG. 2A;

FIGS. 9A-9C illustrate flexion-extension articulation of a subject'swrist joint by the systems of the present disclosure;

FIGS. 10A-10C illustrate abduction-adduction articulation of a subject'swrist joint by the systems of the present disclosure;

FIG. 11 is a block diagram of a sensory rehabilitation training programuseful with the systems of the present disclosure;

FIG. 12 illustrates displacement of a subject's wrist joint as describedin the Examples;

FIG. 13 is a graph showing the testing results of a subject of thetesting described in the Examples section;

FIG. 14 is a plot of psychometric function for a subject of the testingdescribed in the Examples section in the FE plane;

FIG. 15 is a plot of psychometric function in the AA plane for a subjectof the testing described in the Examples section;

FIG. 16 is a graph of discrimination thresholds and standard deviationsof the testing described in the Examples section;

FIG. 17 is a box plot of thresholds in the FE and AA conditions for thetesting described in the Examples section;

FIG. 18 is a graph of FE discrimination thresholds versus AAdiscrimination thresholds for the testing described in the Examplessection; and

FIG. 19 is a plot of discrimination thresholds for FE conditions acrossthree different experimental sessions of the testing described in theExamples section.

DETAILED DESCRIPTION

One embodiment of a wrist joint proprioception system 20 function inaccordance with principles of the present disclosure is shown in blockform in FIG. 1. The systems 20 of the present disclosure include amanipulandum unit 22 and a controller 24. Details on the variouscomponents are provided below. In general terms, however, themanipulandum unit 22 is a robotic-type device, generally configured toreceive a subject's forearm and hand, and to establish a threedegrees-of-freedom (DOF) environment in which the subject's wrist can becontrollably and independently manipulated about three axes of rotation(in accord to and within the anatomical range of motion of naturalplanes of wrist movements). The controller 24 is programmed to controloperation of the manipulandum unit 22 in a pre-determined fashion. Inthis regard, the controller 24 can be programmed to effectuateperformance of one or more proprioceptive assessment routines at themanipulandum unit 22 and from which proprioceptive function of thesubject's wrist is objectively assessed in a standardized manner. Insome embodiments, the controller 24 is further programmed effectuateperformance of one or more proprioceptive rehabilitation trainingroutines at the manipulandum unit 22 and selected to improve motorfunction of the subject's wrist. In related embodiments, the system 20can include one or more displays 26 that are operated by the controllerto create a virtual reality environment as part of the rehabilitationtraining.

One embodiment of the manipulandum unit 22 useful with the systems ofthe present disclosure is shown in FIGS. 2A and 2B. The unit 22generally includes a base or splint 42, a handle 44, a linkage assembly46 (referenced generally), and a plurality of motors (not shown). Thelinkage assembly 46 connects the handle 44 with the base 42, andestablishes three DOF of movement the handle 44 relative to the base 42.As made clear below, the three axes about which the three DOFs areestablished at the manipulandum unit 22 can be designated in accordancewith three axes of wrist joint rotation when manipulated by the unit 22;namely, pronation/supination (PS), flexion/extension (FE), andabduction/adduction (AA). The motors are connected to the linkageassembly 46 and dictate or actuate movement of the handle 44 via thelinkage assembly 46.

The base 42 is generally sized and shaped to ergonomically receive ahuman forearm, and optionally presents or provides a support surface 50against which a subject's forearm will comfortably rest while thesubject's hand or palm is grasping the handle 44. The support surface 50can have the curved shape as shown. For reasons made clear below, thebase 42 can be viewed as establishing a reference axis R relative towhich movement axes of the linkage assembly 46 can be defined. Thereference axis R represents an approximate longitudinal centerline ofthe support surface 50; a centerline of a subject's forearm will besubstantially parallel with the reference axis R when resting on thesupport surface 50 (it being understood that the forearm centerline willnecessarily be above (relative to the orientation of the views) thereference axis R when the forearm lies on the support surface 50).

In some embodiments, the base 42 can be attached to an optional carrier52. The carrier 52 includes a floor 54, a bracket 56 and a platform 58.The floor 54 is configured to promote rigid attachment of the carrier 52(and thus the base 42) to a stationary surface such as a tabletop,whereas the platform 58 robustly supports the base 42. The bracket 56supports the platform 58 relative to the floor 54, and is adapted toreceive and support portions of the linkage assembly 46 and acorresponding one of the motors as described below. The carrier 52 canassume a wide variety of other forms commensurate with a construction ofthe base 42 and/or the linkage assembly 46. In other embodiments, thecarrier 52 can be omitted.

The handle 44 can assume various forms and is generally configured topromote ergonomic gripping thereof by a subject's hand or palm. In someembodiments, the handle 44 can include a grip member 60 and a post 62.The grip member 60 can be formed of a compliant material (e.g., foam,rubber, etc.), and can be contoured for comfortable gripping by asubject's hand. The grip member 60 is disposed over the post 62 that inturn is adapted for attachment to the linkage assembly 46 as describedbelow.

The linkage assembly 46 interconnects the base 42 and the handle 44, andgenerally includes or provides a PS transmission sub-assembly 70 and aFE transmission sub-assembly 72 as best reflected in FIG. 3. Asdescribed below, connection between the PS transmission sub-assembly 70and the FE transmission sub-assembly 72 establishes an AA transmissionarrangement.

With additional reference to the exploded view of FIG. 4, the PStransmission sub-assembly 70 includes a track 80 and opposing, first andsecond arms 82, 84. The track 80 can assume various forms configured fortranslatable coupling with the output shaft of a motor (not shown). Thetrack 80 can have the semi-circular or U-shape shown, and in someembodiments includes first and second track members 90, 92. The trackmembers 90, 92 can have an identical size and shape (e.g., thesemi-circular or U-shape reflected in the views). With optionalembodiments of the manipulandum unit 40 that otherwise include thecarrier 52, the track members 90, 92 are configured to be slidablymounted relative to the carrier 52, for example with the first trackmember 90 being disposed within the bracket 56 and the second trackmember 92 located outside of the bracket 56. Regardless, assembly of thetrack 80 relative to the carrier 52 is such that the track 80 can rotaterelative to the carrier 52 as described below, for example by pivotingor rotating about a centerline of the semi-circle or U shape generatedby the track 80. In this regard, the track 80 is configured in tandemwith the mounting arrangement relative to the carrier 52 such that thecenterline of the shape of the track 80 (and about which the track 80 isarticulated) is substantially parallel with but above (relative to theorientation of the views) the reference axis R of the base 42. Forexample, the centerline of the track 80 shape is generally located to bein-line with an expected centerline of a subject's forearm when restingon the support surface 52 (it being understood that different subjectswill have differently-sized forearms such that the centerline of thetrack 80 will invariably be slightly offset with the subject's forearmcenterline). Finally, at least the first track member 90 incorporatesmounting features appropriate for connection with the motor (not shown)output shaft, such as a slot 94.

The arms 82, 84 can be substantially identical (e.g., mirror images),generally configured for connection to opposite ends, respectively, ofthe track 80. As identified for the second arm 84, each of the arms 82,84 are connected to the respective mounting rings 110, 112 that eachterminate at or form a leading end 102. The leading end 102 isconfigured to facilitate a pivotable or hinged connection with acorresponding component of the FE transmission sub-assembly 72. Forexample, the leading end 102 can include or form a bore 104 sized andshaped to rotatably receive a pin, shaft or other mounting body (notshown). Other mounting techniques are also acceptable. Regardless, acommon AA axis (shown in FIG. 3) of the manipulandum unit 22 isestablished at the leading end 102 of the arms 82, 84 and about whichthe FE transmission sub-assembly 72 can pivot relative to the arms 82,84 (and thus relative to the PS transmission sub-assembly 70).

Each of the arms 82, 84 is optionally configured to be rigidly connectedto or carry a motor M3, M4, locating an output shaft of the motor M3, M4to interface with a corresponding component carried by, or connected to,the FE transmission sub-assembly 72. Each motor M3, M4 can be mounted tothe corresponding arm 82, 84 in various fashions. In some embodiments,for example, the mounting ring 110 is attached to and extends from thefirst arm 82, and the identical mounting ring 112 is attached to andextends from the second arm 84. The mounting rings 110, 112 can assumeany format appropriate for rigidly supporting the corresponding motor,and can be located at any location along a length of the correspondingarm body 102 appropriate for spatially locating the motor's output shaftat a desired position relative to the leading end 102 for interfacingwith the FE transmission sub-assembly 72 as described below.

The arms 82, 84 can be connected to the track 80 in various manners. Insome embodiments, a fixed-type connection is provided, for example by aconnector body 114 coupling the first arm 82 to a first end of the track80, and a connector body 116 coupling the second arm 84 to an opposite,second end of the track 80. The connector bodies 114, 116 can beidentical. As identified for the second connector body 116 in FIG. 4,each of the connector bodies 114, 116 includes a platform 120. Theplatform 120 provides a flat surface for rigidly receiving andmaintaining the arm 82 and 84. Other mounting constructions are equallyacceptable, and in other embodiments the arms 82, 84 can be rigidlyfixed to the track 80.

One embodiment of the FE transmission sub-assembly 72 is shown ingreater detail in FIG. 5 (along with the handle 44). Withcross-reference between FIGS. 3 and 5, the FE transmission sub-assembly72 includes a guide track 120, a carriage 122, and opposing, first andsecond legs 124, 126. In general terms, the legs 124, 126 maintain theguide track 120 relative to the PS transmission sub-assembly 70. Thecarriage 122 supports a motor M2 relative to the guide track 120. Thehandle 44 is coupled to the carriage 122, for example via an optionalrail 128. With this construction, the motor operates to articulate thecarriage 122 (and thus the handle 44) along the guide track 120.

The guide track 120 is sized and shaped to establish a desired path oftravel for the carriage 122, and in some embodiments approximates asemi-circle (or U-shape). Other shapes, and thus other paths of travel,are envisioned that may include curved segments presenting two or morediffering radii of curvature, curvilinear segments, linear segments,etc. With embodiments in which the shape of the guide track 120 is asemi-circle (or other shape having a single radius of curvature), acenterline of the so-generated shape establishes an FE axis of themanipulandum unit 22 and about which the carriage 122 (and thus thehandle 44) articulates. The guide track 120 incorporates one or morecoupling features appropriate for interfacing with an output shaft ofthe motor M2 mounted to the carriage 122, for example a slot 130. Insome embodiments, an optional support track 132 is provided, having asize and shape approximating that of the guide track 120. The supporttrack 132 is configured to reinforce the guide track 120 and promote amore robust coupling of the guide track 120 with the legs 124, 126.

The carriage 122 can assume various forms appropriate for maintainingthe motor (not shown), and in particular ensuring an engaged interfacebetween an output shaft of the motor and the corresponding couplingfeature (e.g. the slot 130) of the guide track 120. In some embodiments,the carriage 122 includes opposing housing sections 140, 142 configuredfor mated assembly, and one or more optional bearings 144 (visible inFIG. 5). The bearings 144 are rotatably disposed within the housingsections 140, 142, and promote smooth movement or articulation of thecarriage 122 (and the motor) along a shape of the guide track 120.

The handle 44 can be attached to the carriage 122 in various fashions.For example, in some embodiments, the handle 44 can be directly mountedor fixed to the carriage 122. In other embodiments, the FE transmissionsub-assembly 72 can be configured such that handle 44 is connected tothe carriage 122 in a manner permitting selective re-positioning of thehandle 44. For example, the rail 128 can be interposed between thehandle 44 and the carriage 122. The rail 128 is an elongated bodyadapted for mounted assembly to the carriage 122 (e.g., to the upperhousing section 140). A slide body 150 is disposed along the rail 128,and is configured for coupling with the handle 44 (e.g., via a foot 152provided with the handle 44). The slide body 150 can establish africtional-type engagement with the rail 128, but can be slid orarticulated along a length of the rail 128 when subjected to sufficientexternal force. In other words, the slide body 150 does not freely slidealong the rail 128, but instead will self-maintain a selected positionrelative to the rail 128 unless subjected to an overt force. Upon finalassembly, the slide body 150, and thus the handle 44, can be selectivelyre-positioned or adjusted along a length of the rail 128 as desired.This adjustable arrangement promotes use of the manipulandum unit 22properly scaled to a subject's anthropometrics (e.g., differences inforearm length between an adult and a child; adult subjects may preferto locate the handle 44 at a greater distance from the carriage 122 ascompared to child subjects). Optional stops 154 can be assembled toopposite ends of the rail 128 to prevent the slide body 150 frominadvertently sliding off of the rail 128.

The legs 124, 126 can be substantially identical in some embodiments(e.g., mirror images), and are generally sized and shaped for assemblyto the guide track 120 and for connection with a corresponding one ofthe PS transmission sub-assembly arms 82, 84. As identified for thefirst leg 124, each of the legs 124, 126 can include or define a legbody 160 terminating at or forming a head 162. The head 162 isconfigured to facilitate a pivotable or hinged connection with acorresponding component of the PS transmission sub-assembly 70. Forexample, the head 162 can include or form a bore 164 sized and shaped torotatably receive a pin, shaft or other mounting body (not shown). Othermounting techniques are also acceptable.

Regardless, upon final assembly the common AA axis as described above isestablished at the head 162 of the legs 124, 126 and about which the FEtransmission sub-assembly 72 can pivot relative to the PS transmissionsub-assembly 70 as described below.

Upon final assembly, and as reflected in FIGS. 2A and 2B, the PStransmission sub-assembly 70 and the FE transmission sub-assembly 72 arelinked to one another at corresponding pairs of the arms 82, 84 and legs124, 126. In particular, the first arm 82 is connected to the first leg124, and the second arm 84 is connected to the second leg 126. Theconnection format can assume various forms capable of establishing apivotable relationship between the arms 82, 84 and the legs 124, 126.For example, and as alluded to above, a pin or similar body (not shown)can be provided at each arm/leg interface that connects the arm 82, 84with the corresponding leg 124, 126 in a manner permitting rotation ofthe leg 124, 126 relative to the corresponding arm 82, 84 about the pin.Regardless of exact form, the FE transmission sub-assembly 72 ispivotable relative to the transmission sub-assembly 70 about the AAaxis.

With additional reference to FIGS. 6A-6C, the linkage assembly 46permits movement of the handle 44 relative to the base 42 with three DOFin which the handle 44 can be articulate about three axes. The threeaxes or DOF can be designated with reference to anatomical movements ofthe human wrist joint when manipulated by the unit 22. As identified inFIGS. 6A-6C, the connection between the arms 82, 84 and the legs 124,126 permits pivoting or articulation of the handle 44 relative to thebase 42 about the AA axis that otherwise induces withabduction-adduction movement of the wrist joint in a sagittal or AAplane of the unit 22. The connection between the handle 44 and the guidetrack 120 (via the carriage 122) permits pivoting or articulation of thehandle 44 relative to the base 42 about an FE axis of the unit 22 thatotherwise induces flexion-extension movement of the wrist joint in atransverse or FE plane of the unit 22. Finally, the connection betweenthe track 80 and the base 42 permits pivoting or articulation of thehandle 44 relative to the base 42 about a PS axis of the unit 22 thatotherwise induces pronation-supination movement the subject's hand in aPS plane of the unit 22. The AA, FE, and PS axes have prescribedrelationships relative to one another and relative to the reference axisR of the base 42 so as to ergonomically coincide with anatomicalmovements of a subject's wrist joint and hand when the forearm rests onthe base 42 and the hand grasps the handle 44. For example, the PS axisis substantially parallel (e.g., within 5 degrees of a truly parallelrelationship) with the reference axis R. The FE axis is substantiallyperpendicular to (e.g., within 5 degrees of a truly perpendicularrelationship) the PS axis and to the reference axis R. Finally, the AAaxis is substantially perpendicular to (e.g., within 5 degrees of atruly perpendicular relationship) the FE axis and the PS axis (and thusalso the reference axis R). It has surprisingly been found that thenon-limiting example of the manipulandum unit 40 as described aboveprovides a range of motion (ROM) of the three DOFs that substantiallymatches the ROM of an adult human wrist. For example, some embodimentsof the manipulandum units of the present disclosure have a ROM about theFE axis of +−72 degrees; about the AA axis of 45 degrees/27 degrees;about the PS axis of +−80 degrees. By way of comparison, the human wristjoint typically presents a ROM in flexion/extension of 65 degrees/70degrees; in abduction/adduction of 15 degrees/30 degrees; inpronation/supination of +−90 degrees.

As mentioned above, the manipulandum unit 22 includes one or more motorsM1-M4 interfacing with the linkage assembly 46, and in particularcontrolling or dictating a stationary spatial position of the handle 44relative to the base 42 as well as movement of the handle 44 about eachof the AA, FE, and PS axes. In some embodiments, a first motor (notshown, but a possible location of which is referenced in the Figures at“M1”) is operably associated with the track 80, for example by assemblyto the carrier 52. The first motor M1 can take various forms, and isgenerally configured such that an output shaft of the first motor M1 iscoupled to the track 80, with movement (e.g., rotation) of the firstmotor M1 output shaft causing the track 80 to articulate (i.e., duringoperation, the first motor M1 remains stationary while the track 80 isactuated to move). Commensurate with previous explanations, then,operation of the first motor M1 corresponds with movement of the handle44 relative to the base 42 about the PS axis. Further, the first motorM1 and the first motor M1/track 80 interface is configured such that thefirst motor M1 resists or prevents movement of the track 80 when theoutput shaft of the first motor M1 is not rotationally driven. In otherwords, the first motor M1 serves to dictate and maintain a spatialposition of the handle 44 in the PS plane of the manipulandum unit 22.

The second motor M2 is operably associated with the guide track 120, forexample by assembly to the carriage 122. The second motor M2 can takevarious forms, and is generally configured such that an output shaft ofthe second motor M2 is coupled to the guide track 120, with movement(e.g., rotation) of the second motor M2 output shaft causing the secondmotor M2 (and thus the carriage 122 and the handle 44) to articulatealong or relative to the guide track 120 (i.e., during operation, theguide track 120 remains stationary while the second motor M2 (and handle44) is actuated to move). Commensurate with previous explanations, then,operation of the second motor M2 corresponds with movement of the handle44 relative to the base 42 about the FE axis. Further, the second motorM2 and the second motor M2/guide track 120 interface is configured suchthat the second motor M2 resists or prevents movement of the secondmotor M2 relative to the guide track 120 when the output shaft of thesecond motor M2 is not rotationally driven. In other words, the secondmotor M2 serves to dictate and maintain a spatial position of the handle44 in the FE plane of the manipulandum unit 22.

The third motor M3 is operably associated with the pivotable connectionbetween the first arm 82 and the first leg 124. The fourth motor M4 isoperably associated with the pivotable connection between the second arm84 and the second leg 126. Transmission to the leg 126 can be obtainedby a geared mechanism N1, N2 including pulleys, a belt and pinion or thelike. The third and fourth motors M3, M4 can take various forms. Thethird motor M3 is generally configured such that an output shaft of thethird motor M3 is coupled (directly or indirectly) to the head 162 ofthe first leg 124, with movement (e.g., rotation) of the third motor M3output shaft causing the first leg 124 to articulate or pivot relativeto the first arm 82 (i.e., during operation of the third motor M3, thefirst arm 82 remains stationary while the first leg 124 is actuated tomove). Coupling of the third motor M3 with the first leg 124 can beachieved in various manners, and in some embodiments can entail a gearG, belt B and pulley P type arrangement (see, in particular, FIG. 4). Asimilar relationship can be provided between the fourth motor M4relative to the second leg 126. The third and fourth motors M3, M4 canbe operated in tandem. Commensurate with previous explanations, then,operation of the third and fourth motors M3, M4 corresponds withmovement of the handle 44 relative to the base 42 about the AA axis.Further, the third and fourth motors M3, M4 and the correspondinginterfaces with the legs 124, 126 is configured such that the third andfourth motors M3, M4 resist or prevent movement of the legs 124, 126(and thus the handle 44) relative to the arms 82, 84 when the outputshaft of the third and fourth motors M3, M4 are not rotationally driven.In other words, the third and fourth motors M3, M4 serve to dictate andmaintain a spatial position of the handle 44 in the AA plane of themanipulandum unit 22.

In some embodiments, the motors M1-M4 are brushless motors selected toprovide an accurate haptic rendering and provide sufficient force tostabilize a human wrist against gravity and/or overcome expected orpossible muscular forces of a subject (e.g., due to hypertonia(rigidity) or spasticity). In one non-limiting embodiment, themanipulandum unit 22 (via a construction of the linkage assembly 46 andthe selected motors M1-M4) is configured to provide maximum torquevalues in the three DOFs on the order of 1.53 Nm with respect to the FEaxis, 1.63 Nm with respect to the AA axis, and 2.77 Nm with respect tothe PS axis. Other configurations are also envisioned, and in otherembodiments more or less than four of the motors M1-M4 can be included.

Returning to FIG. 1, in some embodiments the controller 24 includes acomputing system or computing device that includes at least oneprocessor and memory. Depending on the exact configuration and type ofcomputing device, the memory may be volatile (such as RAM), non-volatile(such as ROM, flash memory, etc.), or some combination of the two. Thememory used by the controller 24 is an example of computer storage media(e.g., non-transitory computer-readable storage media storingcomputer-executable instructions for performing a method). Computerstorage media used by the controller 24 according to some embodimentsincludes volatile and nonvolatile, removable and non-removable mediaimplemented in any suitable method or technology for storage ofinformation such as computer readable instructions, data structures,program modules or other data. Computer storage media includes, but isnot limited to, RAM, ROM, EEPROM, flash memory or other memorytechnology, CD-ROM, digital versatile disks (DVD) or other opticalstorage, magnetic cassettes, magnetic tape, magnetic disk storage orother magnetic storage devices, or any other medium that can be used tostore the desired information and that can be accessed by the controller24.

Regardless of exact form, and with additional reference to FIGS. 2A and2B, the controller 24 is configured or programed to control operationof, and receive (and optionally act upon) information or data generatedat, the motor(s) M1-M4 provided with the manipulandum unit 22. Forexample, in some embodiments an angular position or rotation on thethree axes (AA axis, FE axis, PS axis) of the manipulandum unit 22 aremeasured by means 23 of a rotary encoder provided with each of themotors M1-M4. Rotary encoders are known in the art, and operate toconvert the angular position of motion of the motor's output shaft to adigital or analog code that in turn is indicative of the angularposition or rotation relative to the axis to which the motor M1-M4 isassociated. The rotary encoders can assume a variety of forms (e.g.,digital or analog, absolute or incremental), and in some embodiments aredigital incremental encoders with a resolution of 4098 bits/turn or 2048bits/turn.

The controller 24 incorporates appropriate input/output modules forinterfacing (e.g., wired or wirelessly) with the manipulandum unit 22,the display(s) 26, and any other equipment provided with the system 20over which control is desired. For example, the controller 24 caninclude an analog and digital I/O PCI card (available from Sensorayunder the trade designation “Model 626”). The input/output module(s) canprovide multiple interface channels, for example four 14 bit D/Achannels for commanding the reference values of the currents of themotors M1-M4, and four 24-bit counters for receiving the repetitionsignals of the digital encoders. For example, the controller 24 can beconnected through an Ethernet interface directly with motor controlcards used for commanding the reference values of the currents of themotors M1-M4 and for receiving signals of the digital encoders. Anyother interface format known to those of ordinary skill are alsoacceptable.

As described in greater detail below, the controller 24 is programmed(e.g., software or stored in memory) actuate the manipulandum unit 22(i.e., actuate selective ones of the motors M1-M4 that in act upon thelinkage assembly 46 to manipulate the handle 44 relative to the base 42)to perform various, pre-determined operations, such as proprioceptionassessment and/or rehabilitation operations. Further, the controller 24can prompt operation of the display 26 (where provided) in connectionwith one or more of the pre-determined operations. With this in mind,the controller 24 can include a control architecture for effectuatingperformance of the pre-determined operations, such as a controlarchitecture based on three loops: 1) an inner loop, for example runningat 1 kHz, 7 kHz or 20 kHz, for controlling the motor servos; 2) anintermediate loop, for example running at 1 kHz on a real time kernel,that updates the current reference of each motor; 3) an external loop,for example running at 100 Hz, for a visual virtual reality generated atthe display 26 (or other user interface).

The controller 24 can be configured or programmed (e.g., software) toperform various proprioception-related operations, including anassessment program and an optionally rehabilitation or training program,that can be independently selected by the subject or clinician. Oneembodiment of a proprioception or sensory assessment program 300 usefulwith the present disclosure is shown in block form in FIG. 7. Theassessment program 300 includes a plurality of individual routines ormodules that can be categorized based upon related subject matter. Forexample, the assessment program 300 can include a Position Sensecategory 302 and a Motion Sense category 304. The phrase “positionsense” refers to a subject's ability to perceive the position of his/herwrist. The phrase “motion sense” refers to the subject's ability toperceive motion around the wrist joint. Under each category, one or moreindependent modules or routines are available for selection by thesubject or clinician and that each objectively tests one aspect ofproprioceptive function. The individual modules or routines can bewritten in any acceptable programming language known in the art (e.g.,Matlab Simulink Technical Programming Language, C++ or Python). Theroutines are premised upon a subject's interface with the manipulandumunit 22 as generally reflected by FIG. 8. The handle 44 is grasped bythe subject's hand H, while the subject's forearm F rests on the base42. A frontal plane of the subject is generally aligned perpendicular tothe PS axis (FIG. 6A) of the manipulandum unit 22, and the subject'swrist W naturally assumes a neutral joint position. Though not shown, insome embodiments, a strap or similar device can be employed to morefirmly secure the subject's forearm to the base 42. Finally, in someembodiments the routines of the assessment program 300 (FIG. 7) cangenerate more reliable results where the subject's vision is occluded(e.g., opaque glasses) and the subject's hearing is masked (e.g.,noise-cancelling headphones) to eliminate possible visual or acousticcues.

Returning to FIG. 7, the Position Sense category 302 can include aPosition Sense Detection Module S.1. The Position Sense Detection ModuleS.1 is generally programmed to indicate the minimum change in wristposition that a subject is able to perceive. The Position SenseDetection Module S.1 can be programmed to assess the subject's positionsense detection threshold in each of the three DOFs available with themanipulandum unit 22. For example, FIG. 9A reflects a reference positionof the subject's wrist joint W relative to the transverse or FE plane ofthe manipulandum unit 22. The FE axis is also identified. The PositionSense Detection Module S.1 can be programmed to use the referenceposition as a starting point, and then prompt the manipulandum unit 22(FIG. 2A) to articulate the handle 44, and thus the subject's wristjoint W, about the FE axis to one or more pre-determined positions. Forexample, FIG. 9B reflects movement of the handle 44 (in the transverseplane) to a first or standard position, causing the subject's wristjoint W to experience flexion. Under some scenarios, the Position SenseDetection Module S.1 is programmed to temporarily hold the handle 44(and thus the subject's wrist joint W) in the standard position to allowthe subject to provide an indication as to whether or not s/he perceivesa change from the reference position (e.g., the subject can provide aclinician with a verbal statement indicating whether or not s/he hasperceived a change in position, with this indication be recorded (inwriting or electronically)). After a certain amount of time and/or inresponse to a clinician's prompt, the Position Sense Detection ModuleS.1 is programmed to return the handle 44 back to the referenceposition. This process can be repeated for a multitude of differentpositions about the FE axis, with the collective results providing anobjective assessment of the subject's proprioceptive function about theFE axis. For example, FIG. 9C reflects movement of the handle 44, andthus the subject's wrist joint W, to a different or first comparisonposition. Response(s) (or lack thereof) by the subject to perceivedchanges in the wrist joint W at the standard position and the firstcomparison position (as well as many other positions about the FE axis)can be informative. Similar assessments can be performed relative to theAA axis (as represented, for example, by FIGS. 10A-10C) and the PS axisof the manipulandum unit 22. Upon completion of the Position SenseDetection Module S.1 testing, the results can be compared againststandardized results of others under identical testing conditions and/orsaved for comparison with the results of a subsequent Position SenseDetection Module S.1 testing for the same subject (e.g., following arehabilitation program to better identify or recognize improvements inproprioceptive function).

Returning to FIG. 7, the Position Sense category 302 can also include aPosition Sense Discrimination Module or routine S.2. The Position SenseDiscrimination Module S.1 is generally programmed to indicate thesmallest noticeable difference in two wrist arrangements that a subjectis able to perceive. The Position Sense Discrimination Module S.2 can beprogrammed to assess the subject's position sense discriminationthreshold in each of the three DOFs available with the manipulandum unit22 (FIG. 2A). The Position Sense Discrimination Module S.2 can beprogrammed to actuate the manipulandum unit 22 in manners akin to thedescriptions above with respect to the Position Sense Detect Module S.1,causing the subject's hand to move (articulating the wrist joint) aboutthe corresponding axis of interest to a number of differentpre-determined positions. With the Position Sense Discrimination ModuleS.2, however, the user's wrist joint may be caused to move incrementallybetween various pre-determined positions and need not necessarily returnto the reference position.

The Motion Sense category 304 can include a Motion Sense DetectionModule or routine S.3. The Motion Sense Detection Module S.3 isgenerally programmed to indicate the minimum rate of motion at the wristjoint that a subject is able to perceive. The Motion Sense DetectionModule S.1 can be programmed to assess the subject's motion sensedetection threshold in each of the three DOFs available with themanipulandum unit 22 (FIG. 2A). The Motion Sense Detection Module S.3can be programmed to actuate the manipulandum unit 22 in manners akin tothe descriptions above with respect to the Position Sense Detect ModuleS.1, causing the subject's hand to move (articulating the wrist joint)in the corresponding axis of interest from the reference position to apre-determined position(s), and then back to the reference position, atdifferent rates or speeds. After (or during) each cycle, the subject canbe prompted to indicate whether or not s/he perceives any motion inhis/her wrist joint and/or the “level” or amplitude of motion.

The Motion Sense category 304 can also include a Motion SenseDiscrimination Module or routine S.4. The Motion Sense DiscriminationModule S.4 is generally programmed to indicate the smallest noticeabledifference in two different rates or speed of motion at the wrist jointthat a subject is able to perceive. The Motion Sense DiscriminationModule S.4 can be programmed to assess the subject's motion sensediscrimination threshold in each of the three DOFs available with themanipulandum unit 22 (FIG. 2A). The Motion Sense Discrimination ModuleS.4 can be programmed to actuate the manipulandum unit 22 in mannersakin to the descriptions above with respect to the Position Sense DetectModule S.1, causing the subject's hand to move (in turn articulating thewrist) about the corresponding axis of interest at a number of differentpre-determined rates or speeds. The subject can be prompted to indicatewhich of two (or more) different movement cycles was “faster” than theothers.

Other sensory assessment modules or routines can be provided with thetreatment systems of the present disclosure. By providing objectivetests of different aspects of proprioceptive function, an overall,objective assessment of sensory dysfunction at the subject's wrist jointis provided.

In addition to assessment, the systems of the present disclosure areoptionally configured to perform automated proprioceptive functiontraining or rehabilitation on a subject, via software or otherprogramming provided with the controller 24 (FIG. 1). One embodiment ofa proprioception or sensory rehabilitation training program 400 usefulwith the present disclosure is shown in block form in FIG. 11. Therehabilitation training program 400 includes a plurality of individualroutines or modules that can be categorized based upon related subjectmatter. For example, the rehabilitation training program 400 can includea Discrete category 402 and a Continuous Sensorimotor Training category404. The term “discrete” refers to goal-directed wrist movements frompoint A to point B. The phrase “continuous sensorimotor training” refersto continuous movements (i.e., those that do not have a defined spatialor temporal end). Under each category, one or more independent modulesor routines are available for selection by the subject or clinician, andthat are designed to improve proprioceptive and sensorimotor function.The individual modules or routines can be written in any acceptableprogramming language known in the art (e.g., Matlab Simulink TechnicalProgramming Language, C++ or Phython). The routines are premised upon asubject's interface with the manipulandum unit 22 as generally reflectedby FIG. 8 and as described above. However, for some phases of training,the subject's vision may not be occluded. For example, at the beginningof the training, the subject is provided with visual feedback though theuse of the display 26 (FIG. 1) or other virtual reality tools, promptingthe subject to interface with the manipulandum unit 22 in controllingcertain items or objects as shown on the display 26. More particularly,the controller 24 operates (per the selected routine) to generate avirtual reality environment on the display 26, with the virtuallyreality environment including at least one virtual object that can“move” on or within the display 26 in response to movements at themanipulandum unit 22 (as otherwise controlled by the subject). Thecontroller 24 is programmed to correlate movements at the manipulandumunit 22 on to the display 26. In subsequent phases of training, subjectsmay perform movements without vision, for example relying solely onmemory or may receive additional vibro-tactile feedback during movementexecution through vibromotors typically attached to the skin of theforearm or any other suitable bodily surface.

The Discrete category 402 can include a Center-Out Task module T.1. TheCenter-Out Task module T.1 is generally programmed to present, on thedisplay 26, a virtual or neural cursor that is controlled by the subject(via the manipulandum unit 22) along with a virtual target. The targetis randomly located on the display 26, and the goal is for the subjectto move the virtual cursor over the target and then “hold” the virtualcursor over the target for a pre-determined length of time. TheCenter-Out Task module T.1 can be configured to require subject controlover the virtual cursor in one, two or all three of the movement axes orplanes of the manipulandum unit 22 (i.e., AA axis, FE axis and/or PSaxis). Further, the level of difficulty can be increased as the subjectbecomes increasingly competent in performing or solving the presentedtask.

The Discrete category 402 can include a Follow the Target module T.2.The Follow the Target module T.2 is generally programmed to present, onthe display 26, a virtual or neural cursor that is controlled by thesubject (via the manipulandum unit 22) along with a virtual target. Thetarget is randomly moved on the display 26 from a first point to asecond point, and the goal is for the subject to move the virtual cursorwith the moving target. The Follow the Target module T.2 can beconfigured to require subject control over the virtual cursor in one,two or all three of the movement axes or planes of the manipulandum unit22 (i.e., AA axis, FE axis and/or PS axis). Further, the level ofdifficulty can be increased as the subject becomes increasinglycompetent in performing or solving the presented task.

The Continuous Sensorimotor Training category 404 can include a VirtualObject Balancing module T.3. The Virtual Object Balancing module T.3 isgenerally programmed to present, on the display 26, a small virtual ballon a tiltable surface that is controlled by the subject (via themanipulandum unit 22). The goal is for the subject to keep the ball onthe surface. The Virtual Object Balancing module T.3 can be configuredto require subject control over the virtual cursor in one, two or allthree of the movement axes or planes of the manipulandum unit 22 (i.e.,AA axis, FE axis and/or PS axis). Further, the level of difficulty canbe increased as the subject becomes increasingly competent in performingor solving the presented task.

The Continuous Sensorimotor Training category 404 can include a FigureEight Tracking module T.4. The Figure Eight Tracking module T.4 isgenerally programmed to present, on the display 26, a pattern in theshape of a FIG. 8, along with a virtual or neural cursor that iscontrolled by the subject (via the manipulandum unit 22). The goal isfor the subject to manipulate the virtual cursor within the FIG. 8pattern. Further, the level of difficulty can be increased as thesubject becomes increasingly competent in performing or solving thepresented task.

Other sensory rehabilitation training modules or routines can beprovided with the treatment systems of the present disclosure. Byintegrating assessment and training into a single, automated system,proprioceptive function of a subject in 3 DOFs can be repeatedlyassessed and trained, providing the clinician with an objectiveunderstanding of the subject's progress.

EXAMPLES

To confirm the viability of objective proprioceptive function assessmentwith systems of the present disclosure, experiment sessions wereperformed on subjects using a manipulandum unit akin to that shown anddescribed above with respect to FIGS. 2A and 2B. The manipulandum unitprovided three DOFs, and was powered by four brushless motorscollectively providing continuous torque ranges at the wrist joint of1.53 Nm at the FE axis, 1.63 Nm at the AA axis, and 2.77 Nm on the PSaxis. Angular rotations on the three axes were acquired by means of 4000quadrature-counts/revolution incremental encoders, resulting in aresolution of 0.0075° for FE DOF and 0.0032° for AA DOF. Themanipulandum unit was electronically connected to and controlled by acontroller that also operated a visual virtual reality environment. Thecontroller utilized a three control loop control architecture: 1) aninner loop, running at 1 kHz, in the motor servos; 2) an intermediateloop, running at 1 kHz, on a real time kernel that updates the currentreference of each motor; 3) an external loop, running at 100 Hz, for thevisual virtual reality and user interface. The gain parameters of thePID controller running inside the motor drivers were tuned to deliverysmooth movements desirable for the psychophysical thresholddetermination tests described below.

Eleven right-handed young adults with no known neurological andneuromuscular disorders, (mean age±SD: 26.4±3.4 yrs.) volunteered toparticipate in the study. The Edinburgh Handedness Questionnaire wasadministered to determine handedness. All participants revealed alaterality index of >60 on a [−100 100] scale (mean±SD: 82.7±12.9),where −100 means completely left-handed and 100 completely right-handed,showing that they were right-hand dominant. Only the dominant right handwas evaluated.

Subjects sat next to the manipulandum unit (akin to the representationof FIG. 8). The frontal plane of the body was aligned perpendicularly tothe PS axis of the manipulandum unit, which is horizontal. Seat positionwas adjusted in order to be comfortable for the participants, with theelbow angle of −90°. Particular attention was given to the correctalignment of the wrist joint with the functional axis of themanipulandum unit: to avoid joint misalignment and unwanted relativemovements between the wrist and the manipulandum unit during theexperiment, the subject's forearm was firmly constrained to the base andsecured by Velcro© strips. Subjects were instructed to maintain arelaxed hand grip. Prior to testing the wrist assumed a neutral jointposition during FE condition, while in AA condition the joint wasadducted by 10° from neutral in order to prevent the manipulandum unitfrom reaching the anatomical limit of the workspace during stimuluspresentation.

Vision was occluded by opaque glasses and hearing was masked bynoise-cancelling headphones to eliminate possible visual or acousticcues. A unidirectional 2-alternative-forced-choice (2AFC) discriminationparadigm was chosen. Two different stimuli were presented in each trial:a 15° amplitude stimulus of fixed value (standard stimulus) and theother with variable amplitude across trials (comparison stimulus) andalways higher than the standard as represented in FIG. 12). The term“intensity” was referred to as the difference between the angulardisplacement of the two standard and comparison stimuli. The two stimuliwere presented in random order, separated by a 2-second inter-stimulusinterval. After each trial, the subject verbally indicated whichstimulus was “larger” (i.e. which of the two movements had a largerdisplacement). Based on the subject's response, a comparison stimuluswas selected for the subsequent trial using an adaptive QUEST algorithmdeveloped by Watson & Pelli. In order to provide the subject with a moreheterogeneous task, a random Gaussian noise was added for every trial tothe comparison stimulus set to a maximum of ±20% of the currentcomparison stimulus itself. During each trial the velocity of movementwas kept constant at 6°/s.

The two conditions were tested separately: each session lasted forapproximately 45 minutes with 3 minutes rest after every 15-25 trials inorder to prevent mental fatigue and enhance attention, a prerequisitefor the validity of obtained psychophysical thresholds. The intensity ofthe first trial was set to 7° in order to be easily detectable by allthe subjects.

To obtain a proprioceptive threshold, the frequency of correct responseswhere the comparison stimulus was identified as larger than the standardstimulus was computed across the range of displayed stimuli. Responsedata were then fitted using a cumulative Gaussian function. Apsychometric acuity function Ψ was computed for both the conditions,where Ψ describes the probability that a comparison at x is picked asthe stimulus with the larger intensity. The psychometric function rangesfrom 50% to 100%. This implies that for low stimulus intensities thesubject had a 50% of probability to give the correct answer, while forlarge intensities the comparison was correctly perceived as larger in100% of trials. Based on Ψ, a discrimination threshold was defined asthe intensity such that the subjects identified the comparison as largerwith a frequency of 75%.

Exemplar response data of a single subject are shown in FIG. 13. Duringtesting the differences between standard and comparison stimulusprogressively converged towards a minimum, typically after approximately40-70 trials. Data were visually inspected to verify the absence oflapsing errors in the upper asymptote, as these errors considerablyaffect the shape of the curve introducing bias in threshold estimates.FIGS. 14 and 15 show typical psychometric functions obtained forthreshold detection in the two DOFs of the wrist joint.

The single subject data in FIGS. 14 and 15 reveal that this subject hada higher discrimination threshold for FE when compared to AA, yet wasless certain about his judgments for AA (shallower slope of thefunction). With respect to the complete sample, nine of the 11 subjectsexhibited FE thresholds that were higher than for AA indicating thatboth DOF have distinct acuities. Mean threshold for FE was 2.15°±0.43°and 1.52°±0.36° for AA. A subsequent one-way Analysis of Varianceindicated that the mean thresholds for each DF were significantlydifferent from each other (p=0.0013). FIGS. 16 and 17 summarize thethresholds for all the subjects, reporting the mean and the standarddeviation. The two subjects with a lower proprioceptive acuity in FEcompared to AA condition are the ones that performed best in the FEtest: 1.47° and 1.52° for subjects 3 and 11 respectively as betternoticeable in FIG. 18.

A subset of 5 subjects was retested under the identical experimentalprocedure for the FE condition resulting in a total of three differenttest sessions performed in three different days. Results are shown inFIG. 19, where negligible inter-test variability is observable ensuringthat the method is time independent and test-retest reliable.

The feasibility of a three degrees-of-freedom wrist robot system wasevaluated to determine proprioceptive discrimination thresholds for twodifferent DOF of the wrist. Specifically, three goals were pursued.First, to establish data validity meaning that the system producesmeasures of proprioceptive acuity that are in accordance to previouslypublished results on proprioceptive acuity of the human wrist. Second,to show that the system is sensitive to detect small differences inacuity. Third, to establish values for the test-retest reliability ofthe system indicating that the approach provides reliable estimates ofproprioceptive acuity over repeated testing.

The above approach yielded proprioceptive thresholds for two DOF of thehuman wrist. Mean discrimination threshold for FE was 2.15° and 1.52°for AA. When expressing these thresholds with respect to the standarddisplacement of 15°, the threshold for FE is about 14.3% of the size ofthe standard and approximately 10.1% for the AA DOF.

Proprioceptive acuity of the upper limb joints have been measured andreported by previous studies. Unfortunately, no norm data on human wristjoint acuity are available and most previous studies used a jointposition matching paradigms to assess proprioceptive function. Employingsuch a joint position matching paradigm, Lephart (1994) showedrepositioning errors in the range of 12-31% of the target joint angle innormal shoulder joints. In a recent review, Goble (2010) reportedabsolute position matching errors in the magnitude of 2.5° for the elbowjoint. Even though these studies are not directly comparable with thecurrent results because they reflect proprioceptive acuity of the elbowand not the wrist and were measured by joint position matchingparadigms, they nevertheless serve as an estimate of the expectedproprioceptive acuity of upper limb joints. A recent study by Elangovan(2014) using the same psychophysical approach as the systems of thepresent disclosure reported a mean elbow joint discrimination thresholdof 1.05°, which was approximately 10% of the standard of 10°. Thisfinding coincides very closely with the results obtained by the systemsof the present disclosure at the wrist joint. Moreover, because theabove analyses use a psychophysical method, the results should provide amore precise acuity measure for the wrist joint. The same study byElangovan (2014) also revealed that psychophysical thresholds were themost precise and least variable acuity measure. The psychophysicalestimate was significantly lower than mean position errors obtained byipsi- or contralateral joint position matching tasks (ipsilateral:1.51°; contralateral: 1.84°)—a 44% to 75% difference in measurementaccuracy. These findings underline that measurements of wrist jointacuity with the systems of the present disclosure are within thepreviously reported physiological range of upper limb acuity,demonstrating that the systems of the present disclosure are capable ofproducing valid and accurate measures of wrist joint acuity.

Furthermore it was found that the acuity for AA is significantly higherthan for FE. While this may be surprising on a first glance, it may be avery plausible finding if considering the neuroanatomy of the humanwrist joint. It is known that the ligaments stabilizing the wristcontain mechanoreceptors, Ruffini and Pacini-like corpuscles, whichcontribute to wrist proprioception. Immunohistochemical studies of thewrist joint ligaments revealed a rich distribution of mechanoreceptorsin the dorso-radial ligaments such as dorsal radiocarpal, dorsalintercarpal and scapholunate interosseous ligaments, a medium density inthe volar and volar-triquetral ligaments, while others such as the longradiolunate ligament are nearly void of mechanoreceptors (Hagert, 2005;Hagert, 2007). The highly innervated dorso-radial ligaments are stressedduring AA, while the lesser innervated ligaments such as the volarligaments get primarily stressed during FE. These differences inmechanoreceptor density and innervation may ultimately lead todifferences in acuity which is reflected in the differences inproprioceptive thresholds in the testing results. Furthermore the AA DOFhas a lower range of motion than FE and forearm pronation/supination,and the presented stimuli (both standard and comparison) during theexperiment scan a wide portion of the whole AA total range. Thedifferences in the thresholds between the two DOFs highlighted the roleof the structural differences in wrist joints and application of robotictechnology can unveil the anisotropy of proprioceptive acuity among thedifferent human joint, providing more insights also in motor learningand explaining why particular pattern of muscular activations arepreferred for determined tasks.

Given that the thresholds are based on the verbal responses of a subjectto a specific set of displacements, the sensitivity of the system isdetermined by the ability of the motors to create a precise displacementand by the sensitivity of the encoders recording the displacement. Theresolution of the motors passively input the stimuli during theexperiment is 0.2° for FE and 0.3° for AA, the resolution of theencoders is 0.0075° for FE and 0.0032° for AA. Motor and sensorresolution are well below the obtained proprioceptive thresholds,although it must be taken into account that quantization of motion andsmall joint misalignments of the wrist might introduce a certain levelof inaccuracy even if negligible. Furthermore, the nature of theexperimental paradigm (2-alternative-forced-choice discriminationparadigm) may also introduce a bias in subjects if they are notcorrectly trained before initiating the test. The experiments weredesigned in order to present the two stimuli (standard and comparison)pseudorandom either the first or the second stimulus throughout thewhole task. To evaluate subjects' bias, the effect of stimulus order onthe correct response was tested, and showed no differences. Therefore,it can be affirmed that the inherent limitations of both robotictechnology and experimental paradigm do not jeopardize the applicationof robotic technology in the proprioceptive assessment.

To assess test-retest reliability of the threshold estimates, the aboveprocedures were repeated for two additional times (T2 and T3) in fivesubjects only for the FE condition. The coefficients of test-retestreliability were r=0.986 for T2 with respect T1 and r=0.971 for T3 withrespect to T2. The mean within-subject variability across all threetests was s=0.09. The results highlight excellent reliability. Theproposed approach thus is repeatable, a key attribute of a quantitativemeasuring system. Given the precision of the motors and sensors, themost import source of variability of the threshold estimates across thesessions is likely the variability of a subject's verbal responsesacross different test dates to identical stimuli.

Although robotic technology has been widely promoted for use inrehabilitation (Dechaumont-Palacin, 2008; Prange, 2006), its applicationfor diagnostics of proprioceptive function is still in its infancy. Itis believed that no previous studies using haptic-capable roboticdevices reported wrist proprioceptive discrimination thresholds forjoint position sense. Based on established psychophysical assessmentmethods known to produce reliable and accurate results forquantification of proprioceptive discrimination thresholds (Elangovan,2014), the present disclosure employs a robotic device to accuratelydeliver in a repetitive way position stimuli in two different anatomicalplanes of movement and consequently measured wrist proprioceptiveacuity. The findings provide evidence for the feasibility ofrobotic-aided proprioceptive assessment. They further supported astandard paradigm for proprioceptive discrimination thresholds in humanupper limb which should not be limited to the distal part of the arm butshould be extended to different anatomical districts for multi-jointinvestigation in future studies.

The data collected pursuant to the Examples of the present disclosureallowed the determination of the proprioceptive acuity thresholds of FEand AA DOFs of human wrist joint in healthy subjects. Beyond itsneuroscientific relevance, this result introduces, for the first time,the use of a robotic interface to assess proprioceptive acuity of thewrist joint. It has been shown that the technology can generate robust,reliable and unbiased measures of proprioceptive function that allow forthe efficient quantification of proprioceptive status and dysfunction.The use of a robotic system provides multiple advantages: it increasesmeasurement resolution and precision, has good test-retestrepeatability, avoids the problem of poor inter-rater reliability commonin many clinical scales and reduces the variability of the reportedoutcome measures. Consequently, if properly employed, it can reducecosts by reducing the reliance of a clinician or therapist to obtainproprioceptive diagnostics.

The above findings support the use of an integrated robotic device todeliver rehabilitation in the form of sensory and motor intervention aswell as to assess the progress in proprioception occurring as a resultof the robotic intervention in an unbiased manner. Such a device apartfrom providing multimodal sensory feedback (visual, tactile and haptic)can also be used to deliver and modify treatment interventions based onthe monitored progress in proprioceptive recovery. An integrated hapticrobotic device that can assess proprioception, monitor subject progressin proprioception and deliver rehabilitation training may increase theefficiency of training and reduce the amount of individual attentionneeded from the clinician. This integration can be implemented withadditional software and minimal hardware enhancements. Although thisintegrated device will automate the assessment and rehabilitativeprocedure, it may not entirely replace a clinician who can deliversophisticated personal human interaction.

Although the present disclosure has been described with reference topreferred embodiments, workers skilled in the art will recognize thatchanges can be made in form and detail without departing from the spiritand scope of the present disclosure. For example, while the treatmentsystems of the present disclosure have been described with reference toassessment (and possible training) of proprioceptive function, otherapplications are envisioned. In other embodiments, the systems of thepresent disclosure can be useful to correlated wrist motion to brainactivity, to study wrist movement control in impaired and unimpairedsubject, as a high performance joystick as general interface foraerospace and aeronautical industry applications, etc.

What is claimed is:
 1. A method of training a subject, the methodcomprising: providing a manipulandum unit including handle, at least onemotor having a sensor, and a controller having at least one processor;selecting one training module out of a plurality of training modules;and performing the training module at least in part by manipulating themanipulandum unit; wherein the subject's arm interfaces with the handleto manipulate the manipulandum unit; wherein during the step ofperforming the training module, feedback regarding a position andvelocity of the handle is sent from the at least one sensor to thecontroller and the at least one motor applies force to the handle;further wherein, during the step of performing the training module, themanipulandum unit provides vibro-tactile feedback to skin of the subjectregarding the position and velocity of the handle; wherein themanipulandum unit further includes: a linkage assembly connecting thehandle to a base of the manipulandum unit, the linkage assemblyestablishing three degrees of freedom of movement of the handle relativeto the base, each of the at least one motor operatively connected to thelinkage assembly; and wherein the controller is electronically connectedto the manipulandum unit and programmed to: actuate each of the at leastone motor, and receive feedback information from each sensor; whereinthe manipulandum unit is configured to perform a proprioceptionassessment operation for objectively measuring proprioceptive functionof a wrist joint of the subject, including actuating at least one of theat least one motor to effectuate movement of the handle relative to thebase in a pre-determined manner, the assessment operation including aposition sense routine in which the at least one motor is actuated,based on the feedback information, by the controller to: establish areference position of the handle relative to the base, move the handleabout a first axis from the reference position to a standard position,and from the standard position to the reference position, and move thehandle about the first axis from the reference position to a firstcomparison position, and from the first comparison position to thereference position, wherein the controller is programmed to establish apre-determined difference between the standard position and the firstcomparison position, and further wherein a subject's ability to perceivethe difference is indicative of a subject's proprioceptive wristposition sense acuity as an objective measure of a subject's wrist jointproprioceptive function; wherein the step of selecting the trainingmodule is based on the objective measure.
 2. The method of claim 1,further comprising receiving, via the controller, an assessment of thesubject's proprioceptive function and selecting the training modulebased on the assessment of the subject's proprioceptive function.
 3. Themethod of claim 1, wherein during the step of performing the trainingmodule, the controller is programmed to correlate movements of thehandle to visual feedback on a display.
 4. The method of claim 3,wherein the visual feedback includes at least one virtual object moveswithin the display in response to movements of the handle.
 5. The methodof claim 3, wherein the training module is programmed to present on thedisplay, a virtual target and a virtual cursor that is controlled by thesubject with the handle.
 6. The method of claim 5, wherein the virtualtarget moves on the display from a first point to a second point.
 7. Themethod of claim 3, wherein the training module is programmed to presenton the display, a virtual ball on a virtual surface.
 8. The method ofclaim 7, wherein the training module is programmed to allow the subjectcontrol over at least two movement axes of the handle.
 9. The method ofclaim 3, wherein the training module is programmed to present a figureeight shape on the display.
 10. The method of claim 1, wherein thehandle has three degrees of freedom with respect to the base of themanipulandum unit.
 11. The method of claim 1, wherein during the step ofperforming the training module, the subject's vision is occluded. 12.The method of claim 1, wherein the at least one motor includes fourmotors.
 13. The method of claim 1, wherein a forearm of the subject ispositioned on the base during the step of performing the trainingmodule; further wherein the at least one motor controls a stationaryspatial position of the handle relative to the base as well as movementof the handle about each of AA, FE, and PS axes.
 14. The method of claim1, wherein the at least one motor is a brushless motor.
 15. The methodof claim 1, wherein the sensor is a rotary encoder.
 16. The method ofclaim 1 wherein, during the step of performing the training module, themanipulandum unit provides visual or auditory feedback to the userregarding the position and velocity of the handle.